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Psychological support for lower back pain


Expert reviewer, Judith Smith, MSK Clinical Lead, Bupa UK
Next review due July 2021

If you have lower back pain, staying active and keeping positive are usually the best things you can do to make a quick recovery. But this is often easier said than done.

Treatments that combine both physical and psychological techniques can help improve your mindset to give you a more positive outlook and learn how to manage your pain. This combination of techniques is sometimes referred to by health professionals as psychologically informed practice. It can help to reduce your pain and get you back to normal more quickly.

Woman stretching her back

Understanding back pain

Back pain is very common – around six in 10 people will get it at some point during their life. Most people find that, with a few simple self-help measures, their pain resolves within a few weeks. But if your back pain takes longer to go, it can start to have more impact on your quality of life. If you take time off work with back pain, you may find it increasingly hard to return as time goes on. You may feel in a low mood because of the pain, and this can make the problem worse. People with ongoing back pain can find themselves in a recurring cycle of pain and feeling low.

The key to making a quick recovery is keeping active. Doing your usual activities, rather than avoiding them because of your pain, will help to reduce the pain and get you back to normal. It is easy to assume that if something hurts, you shouldn’t do it. This isn’t always the case – pain doesn’t always mean harm. A qualified therapist can teach you how to work through your back pain and try to overcome it. Even though certain movements may produce some pain, these don’t normally cause any harm.

Emotions and back pain

How you feel and respond to pain is a really complex process. There’s the physiological process – that means whatever’s happened in your body to cause the pain. And then there’s the psychological process – how your brain reacts to the pain. Your pain may be very real. But your perception of it (how bad it feels to you) and how much of an impact it has are both strongly influenced by your feelings, attitudes and beliefs.

So, for instance you may notice that your pain can feel worse if you focus on it or feel negatively about it. It will also have a greater impact on your daily life if you’re feeling stressed or low. And if you fear or avoid activities that you associate with pain, you could end up in a negative cycle by decreasing your activity levels and delaying your recovery.

There are lots of different barriers that can stand in your way of making a good recovery. Here are some examples.

  • Believing that pain and activity are harmful. These may be your own beliefs, but they can be reinforced by family members who may be trying to protect you.
  • Negative actions can reinforce the belief that you’re unwell – for example, staying in bed for a long time.
  • Having a low or negative mood, depression, anxiety or stress.
  • Having low expectations of how well treatment will work.
  • Relying too much on passive treatments (ones that don’t expect you to do anything) such as painkillers, hot and cold packs, massage and electrotherapy.

Steven describes the impact back pain had on his life:

'I lost so much muscle mass in my arms, shoulders and back, just from not being mobile. It had such a psychological effect on me, especially with having two children – I couldn’t pick them up and comfort them. It had a massive negative impact on my life. I couldn’t even join in with my pals on the sports we play, I was no good at home, feeling slightly detached – it was really concerning at one point.’

How a psychological approach can help

If you have negative feelings and beliefs about your back pain, it can be really hard to change your way of thinking. This is where a psychological approach to treatment can help.

Psychological therapy aims to address any negative thoughts, feelings and behaviours around your back pain. Confronting these negative behaviours can allow you to work through your pain and get back to normal. There are different approaches to treatment, which may focus on the following areas.

  • Your behaviour and actions – looking at the things you’re currently doing to manage your pain and how you may be able to improve this.
  • Your thoughts and feelings – aiming to identify and change the negative feelings you may have about your pain and how to deal with it.
  • Your body’s response to pain – learning strategies to manage your body’s reaction to pain, such as tension in your muscles.

People who have psychological therapy as part of their treatment for ongoing back pain have been shown to do better than those who just have standard medical treatments and physiotherapy.

Getting psychological therapy for back pain

If you have back pain that doesn’t seem to be getting any better on its own, it’s worth seeing your GP to talk about your treatment options. Your GP will ask you questions about your symptoms and how you’re managing with your pain. They may use a specific questionnaire to do this and work out which therapies might be best for you. Your GP may recommend you try psychological therapies as part of a treatment package, along with exercise and sometimes manual therapies too. Who you’ll see or where you’ll go for this treatment will depend on services available in your area.

Your GP may be able to refer you to a pain clinic at your local hospital. Pain clinics involve teams of health professionals, including doctors, psychologists and physiotherapists. They often run specific group-based pain management programmes. These programmes aim to teach groups of people with similar problems the best ways to cope with their pain and live a more active life.

Alternatively, your GP may refer you to a physiotherapist who has additional training in psychologically informed treatment of persistent back pain. This means that they can provide a combination of both physical and psychological treatments.

What will happen when I have psychological therapy?

Psychological therapy centres on educating you to identify things that cause or aggravate your pain, and strategies you can use to deal with the pain. Your treatment may involve one or more of the following.

  • Putting strategies in place to help you manage your back pain in a healthy way. This may involve removing unhelpful factors such as relying on painkillers, and instead focusing on increasing exercise and going back to work. You might be given a gradually increasing exercise quota to aim for each week.
  • Identifying any negative beliefs and feelings you have about your pain – and working out how to change them (this is known as cognitive restructuring).
  • Relaxation therapies to reduce tension in your muscles and help with the pain. This might involve teaching you various relaxation and breathing techniques.

If you’re referred onto a pain management programme, you’ll attend sessions with a group of people having similar problems. At the sessions, you’ll learn how to do some gentle exercises and other techniques to relax your mind and body. You’ll also take part in discussion groups focusing on strategies to manage and live with your pain.

Psychological therapy may not make your pain go away but may reduce it and should help you to understand how to manage it better. And by helping to get you back to work and your normal activities, the therapy can help you to recover faster.


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Related information

    • Back pain – low (without radiculopathy). NICE Clinical Knowledge Summaries. cks.nice.org.uk, last revised April 2017
    • Low back pain and sciatica. PatientPlus. patient.info/patientplus, last checked 7 December 2016
    • Henschke N, Ostelo RWJG, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews 2010, Issue 7. doi:10.1002/14651858.CD002014.pub3
    • Main CJ, Soden G, Hill JC, et al. Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial's ‘high-risk’ intervention. Physiotherapy 2012; 98(2):110–16. doi:10.1016/j.physio.2011.03.003
    • Musculoskeletal lower back pain. BMJ Best Practice. bestpractice.bmj.com, last updated April 2018
    • Low back pain and sciatica in over-16s: assessment and management. National Institute of Health and Care Excellence (NICE), November 2016. www.nice.org.uk
    • Nicholas MK, Linton SJ, Watson PJ, et al. Early identification and management of psychological risk factors (‘yellow flags’) in patients with low back pain: a reappraisal. Phys Ther 2011; 91:737–53. doi.org/10.2522/ptj.20100224
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    • What are the treatments? STarT Back Tool. Keele University. www.keele.ac.uk, accessed 5 June 2018
    • People living with pain. The British Pain Society. www.britishpainsociety.org, accessed 5 June 2018
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  • Produced by Pippa Coulter, Freelance Health Editor, July 2018
    Expert reviewer, Judith Smith, MSK Clinical Lead, Bupa UK
    Next review due July 2021



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